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The Ridge Medical Centre

The Ridge Medical Practice serves a patient population of over 25,000 across 4 sites within Bradford District Clinical Commissioning Group (CCG).The practice aims to provide high quality care, whilst working in partnership with other agencies across the health and social care spectrum. The practice team comprises of qualified and experienced staff, who aim to provide patients with the most appropriate services, thus ensuring continued health and wellbeing. The team is keen to support / empower patients with choice, decision making and facilitate patient-centred care. As a practice we are striving towards supporting patients to live, longer, happier and healthier lives.

7 November 2016
Yorkshire and Humber
Local Alliances:
Bradford District Dementia Action Alliance

1. Action Plan

1. The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation’s role in delivering better outcomes for people with dementia and their carers?

35% of the practice population are over the age of 65.The practice is committed to providing accessible, patient focused care whilst supporting families and carers.

As a practice we have a pathway in place for enabling diagnosis of dementia, supporting patients when diagnosed and ongoing care. We work closely with voluntary organisations and practice champions.

The practice offers support with advanced care planning, practical advice, for example fire safety, Herbert Protocol and referrals which include Social Care, Speech and Language and Therapy services.

 All patients with a diagnosis of dementia are added to the Case Management Register, which enables high priority access when patients / carers contact the practice. This in turn alerts the reception team when accessing the patient’s record and alerts the clinical team if a patient has an unplanned admission.

The practice also holds Integrated Care Meetings which enables discussion (following consent) of those patient’s with complex health / social needs.

The above examples, demonstrate the practice embracing the principles of the 7 outcomes.



2. What are the challenges to delivering these outcomes from the perspective of your organisation?

The practice is large and covers 4 sites. We aim to have all staff offering a consistent approach to patients, on a non-clinical or clinical basis and no matter which site.

Time is always a challenge, but with a very committed team we hope to be able to achieve steady progress in improving the services we currently provide.

We are a training practice, education, learning and development is a priority for all staff (clinical and non-clinical).

A key focus is for all clinical staff to be having appropriate / timely discussions with patients , families and carers around advanced care planning.



2. Actions

  • Improving end of life care for patients with dementia.

    Improving end of life care need commitment from the whole practice team (clinical and non-clinical).

    75% of deaths are non-cancer, hence many of these are deaths associated with dementia.

    Clinicians need to improve at having conversations and promoting advanced care planning. There needs to be increased recognition of patients entering end of life and referring to appropriate services.

    Non-clinical staff are often dealing with complex telephone calls or face to face requests at the reception desk. It is important that on opening a patient’s record reception / admin staff understand / recognise that they person maybe on the gold standards framework.

    This action can be monitored through the Gold Standard Framework audit which is a project the practice is involved with.

    Delivery, Implementation

    2016 - Fourth Quarter Update

    New Member

  • Effective, clear communication from all practice staff.

    All practice staff to clearly introduce themselves and offer clear, concise explanations.

    Ensure across all 4 sites signs / notices are clear, easy to follow and accessible.

    Letters / information leaflets are clear, concise and easy to follow.

    Ongoing education and support to all staff regarding communication skills.



    2016 - Fourth Quarter Update

    New Member

  • Supporting Carers

    Informal carers need to be identified and supported in caring for someone with dementia.

    Improved identification of carers, offered Carer Health checks and informed of heath / social support available locally.

    Delivery, Implementation

    2016 - Fourth Quarter Update

    New Member